Spontaneous Resolution of Endobronchial Mycobacterium avium-intracellulare Infection in a Patient with AIDS

are basically in agreement with his statements, we feel a few comments are in order. The extremely high rate of specific benign diagnoses reported by Khouri et a)• from needle biopsies of lung nodules is not the experience of most practitioners, and is probably due to their unique expertise, as well as the fact that in most instances they used an 18 or 20 ga needle to obtain a core of tissue for histologic evaluation, rather than aspiration by a 22 ga needle for cytology, as is the practice in most centers. In less skillful hands one would expect an increased incidence of complications using their technique. A recent negative prior radiograph increases the likelihood that the lung nodule is malignant, and would be a reason not to do needle aspiration. One of our patients developed chest wall implantation following needle aspiration biopsy of a completely resected Tl NO MO lung cancer. Seyfer et al• recently reported a similar occurrence. Chest wall or pleural recurrence from tumor implantation in lesions that are potentially curable certainly is a "significant factor in the decision process" and is a tragic occurrence. We continue to feel strongly that needle aspiration biopsy, with its attendant risks, should be reserved for patients who are not surgical candidates. We agree that if specific patterns of calcification which indicate benignity can be demonstrated by either standard or high-resolution cr scans, neither needle aspiration nor thorocotomy would be required. Perhaps the use of the phantom scan will be refined enough in the future to discriminate benign from malignant lung nodules.•·• As surgeons, we are very sensitive to local recurrence following resection of potentially curable lesions. The point of our editorial is that this is a ve,r y real possibility following needle aspiration oflung cancers, and should be an important consideration in the decisionmaldng process for the evaluation of solitary pulmonary nodules which have a high likelihood of being malignant. William R. Hix, M.D., F.C.C.P., and Benjamin L . Aaron, M.D., F.C.C.P. , George ~hington University Medical Center; Washington, D.C . REFERENCES

1 Khouri NF, Stitik FP, Erozan YS, Gupta PK, Kim WS, Scott WW Jr, et al. Transthoracic needle aspiration biopsy of benign and malignant lung lesions. AJR 1985; 144:281-88 2 Seyfer AE, Walsh DS, Graeber GM, Nuno IN, Eliasson AH. Chest wall implantation oflung cancer after thin-needle aspiration biopsy. Ann Thorac Surg 1989; 48:284-86 3 Ward HB, Pliego M, Diefenthal HC, Humphrey EW. The impact of phantom cr scanning on surgery for the solitary pulmonary nodule. Surgery 1989; 106:734-38 4 Jones FA, Wiedemann HP, O'Donovan PB, Stoller JK. Computerized tomographic densitometry of the solitary pulmonary nodule using a nodule phantom. Chest 1989; 96:779-83

L-Tryptophan Induced Cough and Pleural Effusions Associated with the Eosinophilia-Myalgia Syndrome 7b the Editor: I would like to report a patient with cough and pleural effusions associated with the eosinophilia-myalgia syndrome which was caused by the ingestion of L-tryptophan. L-tryptophan is an overthe-counter preparation used to treat a variety of psychiatric disorders. 1 A 34-year-old white woman presented with a three-week history of severe tightness in the chest, cough and diffuse myalgias. One

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week prior to the onset of her symptoms she started taking one gram of tryptophan. On physical examination she appeared in pain with simple movement and was unable to take a deep breath without coughing. Chest x-ray revealed a faint interstitial inflltrate and small bilateral effusions. Her WBC count was 29,000 with 45 percent eosinophils, which dropped to 11,000 with 38 percent eosinophils on day 21. Aldolase was elevated to 15 mu/ml (normal 1.2 to 7 6. ). The patient improved upon withdrawal of the tryptophan. The CDC has reported more than 300 cases of a new syndrome called the eosinophilia-myalgia syndrome associated with the ingestion of L-tryptophan products. It is interesting to speculate on the possible role of the eosinophil major basic protein in causing the considerable respiratory findings in this patient.• Eric T. Shore , M.D., Clinical Assistant Professor of Medicine , University of Connecticut, Hartford REFERENCES

1 Boman B. L-tryptophan: a rational anti-depressant and a natural hypnotic? Aust NZ J Psychiatry 1988; 22:83-97 2 Gleich GJ, Frigas E, Loegering DA, Wassom DL, Steinmuller L. Cytotoxic properties of the eosinophil major basic protein. J Immunol1979; 123:2725-2927

Spontaneous Resolution of Endobronchial Mycobacterium avlumlntracellulare Infection in a Patient with AIDS 7b the Editor:

We previously reported a case of endobronchial Mycobacterium avium-intracellulare infection (MAl) in a patient with AIDS whom we evaluated fur massive hemoptysis. 1 Bronchoscopic examination initially disclosed no speciflc abnormality with the exception of a fresh clot in the posterior segment of the right upper lobe bronchus. A second bronchoscopy performed for evaluation of recurrent massive hemoptysis revealed a clot in the same location. Bronchial artery embolization of the corresponding vessels was therefore performed to control bleeding. One month later a third bronchoscopy performed as a follow-up evaluation disclosed multiple, partially obstructing, polypoid endobronchial lesions. Endobronchial biopsies were performed. Histologic examination revealed necrotizing and non-necrotizing granulomas, and the tissue cultures ultimately grew MAl. Five months later, recurrent hemoptysis, fever, and a chest radiograph typical of bronchiectasis necessitated endobronchial examination. Polypoid masses occluding multiple bronchial segments were partially removed using biopsy forceps, which allowed drainage of purulent material from the distal airways. During the next nine months, the patient's clinical course was dominated by recurrent maxillary sinusitis resistant to multiple courses of antibiotics (amoxicillin-clavulanate, cipro8oxacin); progressive bilateral, interstitial lower lobe infiltrates; and progressive CMV retinitis. Intravenous DHPG and prophylactic therapy with aerosolized pentamidine and oral zidovudine in addition to cyclic antibiotics (erythromycin, tetracycline, cefadroxil) and monthly gamma globulin injections for control oflower airway infection were utilized over this same period. Bronchoscopy performed for evaluation of the lower lobe interstitial inflltrates 14 months after the initial airway examination demonstrating endobronchial lesions revealed absence of polypoid airway masses (Fig 1). Transbronchial biopsies were unremarkable fur infectious organisms or a specific pathologic abnormality. Cytomegalic virus was recovered from Communications to the Editor

FI CURE 1. Note endobronchial MAl (top) and normal anatomy (bottom) of corresponding bronchial segments following its spontaneous resolution.

bronchoalveolar lavage Huid cultures, but cultures for MAl organisms were negative. The patient continued to experience frequent bouts of sinusitis and minor episodes of hemoptysis. During September, 1989 his sputum cultures again turned positive for MAl. However, bronchoscopy performed on October 10, 1989 revealed no bleeding source or evidence of recurrence of endobronchial MAl . To the best of our knowledge this is the first report in the English literature of spontaneous resolution of endobronchial MAl in a patient with AIDS. None of the medications the patient received during the time of evaluation for hemoptysis and parenchymal lung disease have demonstrated clinical bactericidal activity against MAl, although ciproftoxacin in combination with imipenem and amilcacin has demonstrated in vitro activity against MAI.• We conclude that, similar to parenchymal MAl, endobronchial

MAl may be self-limiting" and hypothesize that in this patient it may reflect immunologic reconstitution, perhaps facilitated by zidovudine and gamma globulin. u The other medications played a minor role at best in the eradication of this infection. Edward M. Cordasco, Jr., D.Q; Thomas Keys, M.D. , FCCP; Atul C. Mehta, M .D., FCCP; Mark E. Mehle, M.D., and David L. Longworth, M.D ., FCCP, The Cleveland Clinic Foundation, Cleveland Reprint requests: Dr. Mehta, Cleveland Clinic Foundation .+90, 1 Clinic Center, Cleveland 44195-5038 CHEST I 98 I 6 I DECEMBER, 1990

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Daisuke Inoue, M.D. KJpto Prefectural University of Medicine,

REFERENCES

1 Mehle ME, Adamo JP, Mehta AC, Wiedemann HP, Keys '[, Longworth DL. Endobronchial Mycobacterium at>lum-intracelWlare infection in a patient with AIDS. Chest 1989; 96:199-201 2 Inderlied CB, Kolonski Pf, Wu M, Young LS. Amikacin, ciproftoxacin, and imipenem treatment for disseminated Mycobacterium at>lum complex infection of beige mice. Antimicrob Agents Chemother 1989; 33L:l76-80 3 Davidson PI: The diagnosis and management of disease caused by M at>ium complex, M karl868ii and other mycobacteria. Clin Chest Med 1989; 10:431-43 4 Fauci AS, Lane, HC. Antiretroviral therapy and immunologic reconstitution in AIDS. Ann Instit Pasteur Immunol 1987; 138:261-68 5 Yarchoan R, Broder S. Development of antiretroviral therapy for the acquired immunodeficiency syndrome and related disorders. A progress report. N Eng! J Med 1987; 316:557-64 6 Yap PL, Williams PE. Treatment of human immunodeficiency virus infected patients with intravenous immunoglobulin. J Hosp Infect 1988; 12:35-46

Wandering Pacemaker 1b the Editor:

An electrocardiographic pattern of irregular, multiform (multi-

focal), supraventricular beats with changing P wave morphology and varying llR intervals has been referred to as wandering pacemaker.

This term has been discouraged by some because it implies a mechanism which is not really known.' Most patients with such arrhythmias are asymptomatic and require no treatment.• We wish to describe a highly unusual case of wandering pacemaker which presented with unusual symptoms and required urgent surgical treatment. Perhaps this should be added to the list of possible mechanisms for wandering pacemaker. A 55-year-old man with a two-year history of frequent syncopal episodes was admitted to the hospital in congestive heart failure. He was diagnosed at that time to have dilated cardiomyopathy with sick sinus syndrome. Temporary pacing was performed immediately and drug therapy was initiated with resolution of symptoms after several days. There was some difficulty establishing steady positioning of the pacing electrode in the dilated right ventricle, and output requirements for the pacing electrode were high. AWI permanent pacemaker was later fixed to the peritoneum of the upper ahdomiual wall for epicardial pacing via the subxipboid approach. The patient was discharged without recurrence of symptoms of congestive heart failure or syncope. One month later, the patient came to the pacemaker clinic where an examination in the supine position revealed normal pacemaker function. He stated that he had been feeling quite well except for an involuntary, pulsatile twitching of the left leg which had begun several days before. He noted that the twitching disappeared when he was lying flat but returned when he sat up, and particularly bothersome to him when be was trying to drive his car. He was immediately taken to the X-ray department where a fluoroscopic examination of the upper abdomen revealed no pacemaker! By following the electrode catheter from the heart, the pacemaker was found sitting at the bottom of the pelvic cavity. The pacemaker was apparently shifting position in accordance with bowel motion, and when the table was tilted 90" to supine it "wandered" hack to the upper abdomen. There were no signs of ileus, but the patient was informed that surgery would be required to prevent bowel complications. In the operating room, the pacemaker was easily "fished" out of the abdomen by pulling on the lead, and firmly repositioned on the surface of upper abdomiual muscle. Now, six months later, he enjoys driving without any recurrence of the pulsatile leg movements.

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~o, japan; and Philip M. Hartigan, M.D ., Brigham and Women$ Hospital,

Boston Reprint requests: Dr. Inoue, 2nd Department of Medicine , KJpto Prefecture UniversityofMedicine, Kawaramochi-Hirokoji , Kamilqpku, ~o 602, japan REFERENCES

1 WHOIISFC 'Thsk Force. Definition of terms related to cardiac rhythm . Eur J Cardiol1978; 8:127-44 2 Curry PVL, Shenasa M. Wandering pacemaker. In: Mandel WJ, ed. Cardiac arrhythmias. Their mechanisms, diagnosis and management. Philadelphia: JB Lippincott, 1987:211-12

Nasal CPAP for Severe Hypoxia 1b the Editor:

We have used 100 percent oxygen nasal CPAP to avoid endotracheal intubation in seven patients with severe hypoxia and bilateral pulmonary infiltrates. Mechanically, the system employed is identical to the nasal CPAP mask conventionally used for sleep apnea, but provision is made for the driving gas to be 100 percent oxygen. Initially, we were treating AIDS patients with Pneumocystis carinii pneumonia (PCP) who had elected not to undergo aggressive life support. Subsequently, we employed nasal CPAP in non-terminal patients who simply wanted to avoid the discomfort and problems of intubation and mechanical ventilation. In each case, arterial Po. was less than 55 torr despite the administration of 80 to 90 percent inspired oxygen by nonrebreather mask before initiating nasal CPAP. All were monitored by oximetry. Clinical data and blood gas changes are shown in Table 1. The duration of treatment varied from three to eight days, after which the patients were transferred to conventional mask or nasal oxygen as their respiratory status improved. After the patients became accustomed to the apparatus, eating and conversation in the usual fashion was possible-a distinct advantage over a full face mask. The greatest objection voiced was that the patients looked like "Porky Pig". Remarkably, each of our patients survived to hospital discharge and none deteriorated enough to require intubation, although we do not suggest an intrinsic therapeutic value. We have not attempted the technique in uncooperative or hypercapnic patients. This approach is simply a blending of full face mask technology long used in ARDS'" with the recognition that human subjects are largely nasal breathers and can even be ventilated via nasal mask with relative comfort ...7 Nasal CPAP is likely safer than face CPAP in terms of risk of emesis and aspiration, hut will not be without anticipated complications.•·• Warren C. Miller; M .D . , F.C.C .P., and john W Mason, R.R .T., Humana EUlmonary Center,

Webster, TX Reprint requests: Dr. Miller; Bay Area EUlmonary Associates, 450 Blossom Street, Suite B, Webster, TX 77598 REFERENCES

1 Greenbaum DM, Millen JE , Eross B, Snyder JY, Grenvik A, Safar P. Continuous positive airway pressure without tracheal intubation in spontaneously breathing patients. Chest 1976; 69:615-20 2 Taylor GJ, Brenner W. Summer WR. Severe viral pneumonia in young adults: therapy with continuous positive airway pressure. Communications to the Editor